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Practical Psoriasis on 2 sides of A4 TYPES OF PSORIASIS And associated findings & treatment options Type of psoriasis Clinical features Precipitating factors Differential diagnosis Treatment options Plaque-type psoriasis Red, thick, scaly lesions with silvery scale Stress, infection, trauma, medications Atopic dermatitis, Irritant dermatitis, Cut. T-cell lymphoma, Pityriasis rubra pilaris Seborrhoeic dermatitis Topical therapy with a combination of: corticosteroids, vit D analogue (Dovonex, Curatoderm), coal tar or tazarotene (Zorac). see regime below Streptococcal throat infection Pityriasis rosea, Secondary syphilis, Drug eruption Many patients who have one attack of guttate psoriasis have no further relapses. Antibiotics unhelpful. If recurrent attacks with a sore throat tonsillectomy. Erupting guttate psoriasis does not respond well to topical therapy. If you’re stuck, try vit D analogue, or moderately potent corticosteroids, or low concentrations of tar and dithranol. Ultraviolet B phototherapy best for resistant cases. Erythematous papules or Stress, infection, plaques studded with pustules; medications usually on palms or soles (known as palmoplantar pustular psoriasis) Pustular drug eruption, Dyshidrotic eczema, Subcorneal pustular dermatosis Often difficult to treat. Vit D analogue or a potent topical corticosteroid may help. Topical coal tar and Dithranol sometimes help. Same as localized with a more general involvement; may be associated with systemic symptoms such as fever, malaise and diarrhea; patient may or may not have had preexisting psoriasis Stress, infection, medications Pustular drug eruption, Subcorneal pustular dermatosis Hospitalisation required for systemic therapy. Severe, intense, generalized Stress, infection, erythema and scaling covering medications entire body; often associated with systemic symptoms; may or may not have had preexisting psoriasis Drug eruption, Eczematous dermatitis, Mycosis fungoides, pityriasis rubra pilaris Hospitalisation required for systemic therapy. (Commonly seen in GP) Guttate psoriasis Teardrop-shaped, pink to (Sometimes seen in GP) salmon, scaly plaques; usually on the trunk, with sparing of palms and soles Pustular psoriasis, localized (Sometimes seen in GP) Acute Pustular psoriasis, generalized (Rarely seen in GP) Erythrodermic psoriasis (Rarely seen in GP) If psoriasis is not controlled with topical therapy, more intensive treatment includes phototherapy, oral retinoids, methotrexate or cyclosporin: requires referral to Dermatology. TYPES OF DRUGS and trade name examples Emollient = Epaderm Mild Steroid = Hydrocortisone 1% Moderately Potent Steroids = Mometasone (Elocon), Eumovate, Betnovate Potent Steroids = Clobetasol proprionate 0.05% (Dermol), Locoid, betametasone diproprionate (Diprosone) Vit D analogues= Calcipotriol (Dovonex) or Tacalcitol (Curatoderm) Anthracene derivative = Dithranol Retinoids = Tazarotene (Zorac) Developed by Dr. Ramesh Mehay, Programme Director (Bradford VTS) www.bradfordvts.co.uk; Nov 2009 Taken from: British Association of Dermatologists: http://www.bad.org.uk (great for info on a variety of skin conditions) and from: ‘Treatment of Psoriasis: An Algorithm-Based Approach for Primary Care Physicians’ by Asha Pardasani (in American Family Physician, Feb 2000 available at http://www.aafp.org/afp/20000201/725.html ) Practical Psoriasis on 2 sides of A4 A GENERAL TREATMENT FRAMEWORK Care is needed when a patient's psoriasis is in an inflammatory, eruptive or unstable phase (red & angry). In these circumstances, the skin may show general, non-specific irritancy to topical agents, and treatment should be confined to emollients or low concentrations of tar and/or corticosteroids. 1. Topical corticosteroids + emollient + either (vit D analogue OR a coal tar product) 2. If no better add anthracene derivative (Dithranol) or Retinoid (Tazarotene [Zorac]) 3. Tar based products are good but smelly and not liked by pts Vit D analogues = Tacalcitol (Curatoderm) or Calcipotriol (Dovonex) Curatoderm, unlike Dovonex, can be used on the face and is applied only once a day (Dovonex = bd) Corticosteroids = Eumovate, Mometasone: esp consider if skin inflamed or v. itchy Consider intralesional corticosteroid injections for notably localised fixed plaques. If lesion is dry & scaly: use ointments When better, taper corticosteroids (and restart as needed for flare-ups); continue the other two An easy regime is use steroid in morning, Curatoderm at night: you can wean off the steroid easier with this regime (unlike the combination creams like Dovobet) Dithranol is applied for 30mins then washed off Dithranol is messy, irritant and stains clothes and bed linen purple... use if desperate (can be effective). Advise to wear old clothes. If still no better, refer to Dermatology. Commonest systemic drugs used for psoriasis are Neo-Tigason(a retinoid), Methotrexate and cyclophosphamide. After that it’s the big immune modulating drugs e.g. infliximab: watch this space as they set to revolutionise management of psoriasis in the next few yrs but currently exceedingly expensive PSORIASIS IN PROBLEM AREAS and treatment Site Special problem Treatment options Scalp Hair-bearing areas are not receptive to ointment vehicles. Can be difficult to manage. For all: Soften the scale with olive, coconut or arachis oil (ideally applied under occlusion (plastic shower cap or cling film), then removed using a detergent shampoo. Cocois scalp ointment can be used to remove thick scales. Best treatment for bad scalp psoriasis is SCC Ung-Sulphur + Salicylic acid ointment (messy but good). Applied at night under a shower cap/towel/turban. Shampoo off next day with polytar. Use nightly for 1-2 weeks, then just need to use once/twice per week. Alternatively: Coal tar shampoo + (Dithranol OR topical steroid or vit D analogue).... less effective but may be okay for milder cases. Nails The thick keratin of the nail blocks absorption of topical agents. For onycholysis, a topical corticosteroid in a solution vehicle may be used under the nail. Systemic therapy may be required to improve severe disease. Genitalia The thin skin of the genitalia is highly sensitive to the adverse effects (atrophy) of topical corticosteroids. A low-potency topical corticosteroid ointment is recommended (Hydrocortisone 1%). Consider vit D analogue (eg Tacalcitol [Curatoderm] or Calcipotriol [Dovonex]). Palms and The thick stratum corneum of palms and soles soles is a barrier to penetration of topical agents. Often difficult to treat. Vit D analogue (eg Tacalcitol [Curatoderm] or Calcipotriol [Dovonex]) or highest-potency topical corticosteroid is recommended. Refer if needed. PROFILES OF TOPICAL AGENTS – some things you should bear in mind before prescribing. Topical agent Inconvenience Emollients (Epaderm) Low-potency Steroids (Hydrocortisone 1%) Medium-potency Steroids (Elocon) High-potency Steroids (Dermol, Locoid, + + + + Skin Atrophy Staining Skin irritation Hypercalcaemia + ++ +++ Diprosone) Topical vit D analogues (Curatoderm, Dovonex) Coal tar preparations Anthracene derivatives (Dithranol) Retinoids (Zorac) + ++ +++ + ++ +++ + + ++ +++ + at 120 g per week Developed by Dr. Ramesh Mehay, Programme Director (Bradford VTS) www.bradfordvts.co.uk; Nov 2009 Taken from: British Association of Dermatologists: http://www.bad.org.uk (great for info on a variety of skin conditions) and from: ‘Treatment of Psoriasis: An Algorithm-Based Approach for Primary Care Physicians’ by Asha Pardasani (in American Family Physician, Feb 2000 available at http://www.aafp.org/afp/20000201/725.html )